The Philosophy of Rhinoplasty

Created on 01st August 2008

Professor Frame of Springfield Hospital discusses his surgical approach to rhinoplasty

The procedure

In aesthetic terms, a rhinoplasty is a procedure that changes the shape of a nose. It is performed using a closed (intra-nasal) method or the open approach. In the closed method there are no external scars but in the open method scars may be visible in the columnella and, perhaps, alar fold areas. Plastic surgeons mainly perform cosmetic or reconstructive rhinoplasty. Occasionally nasal septal surgery is included but this tends to be the domain of ENT surgeons, and is indicated for nasal airway obstruction or perforation. Full general anaesthetic (TIVA), administered by an experienced anaesthetist, is essential to the progress and recovery in this surgery. Open rhinoplasty lifts all of the nasal skin from the nasal skeleton to allow full access but has significant additional morbidity.

The surgery then proceeds according to need, ranging from a simple rasp of the nasal hump, which consists of part nasal bone and part nasal cartilages, to hump reduction, alar reduction, infracture, shortening and cartilage grafting, including the use of spreader grafts to avoid nasal valving. I often do the ‘Eiffel Tower' procedure for rhinoplasty, as it gives a consistently good nose with less in the way of surgical trauma. A splint or cast is normally used for external protection and stabilisation, together with a nasal pack or sponge. The pack is removed at twenty-four hours and the splint remains for two weeks. After removing the external splint the nose swells, then settles, and it is at least six weeks before the patient is totally comfortable with the look and ‘feel' of the nose.

Rhinoplasty is the most important of all the aesthetic procedures for the cosmetic surgeon to understand the potential impact on patient's lives. The procedure should be relatively straightforward and good results are usually achieved, but if it is not the result that the patient wants, then there can be serious comorbidity. Body dysmorphic disorder in many cases presents primarily in individuals who perceive their noses to be the wrong shape, even if it is within the range of normality. Incomplete pre-operative counselling, and unrealistic expectations on behalf of the patient, can lead to self harm of patients or even patients harming the surgeon.

Anatomy

The important aspect to understand is the relationship between the underlying skeleton, consisting of nasal bones, nasal cartilages and alar cartilages, with their attaching tissues (Fig.1), and the overlying soft tissues of muscle, fat and skin. The nose has a function and it has mobility. The senses of smell and taste, air filtering, moisturising and warming, and the ability to flare the nostrils during sporting activity, depend upon the inter-relationship of soft tissues either side of the nasal skeleton, including the mucosa, nasal hairs, conchae, sinuses and cribriform plate.

What can be achieved?

The nose has to be seen in the context of the whole face, body type and ethnicity, i.e. thick sebaceous skin gives a very poor result to rhinoplasty and the Asian and Afro-Caribbean noses are often very challenging if seeking a westernised look. A broad nose can easily be narrowed but an over narrow nose does not look good on a broad face. Some projecting noses are highlighted by other skeletal defects such as malar or mandibular hypoplasia and these may not need to be addressed.

The end result is largely dictated by the anatomy and the starting point but a surgeon should not do a rhinoplasty unless there is the ability and facility to correct any problems within that surgical practice.
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